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Safe Prevention of the Primary Cesarean Delivery: ACOG and SMFM Change the Game

I hope that readers of Science & Sensibility (and anyone working in the field of maternal infant health) are sitting down. Be prepared to be blown away. ACOG and SMFM have just released a joint Obstetric Care Consensus statement that has the potential to turn maternity care in the USA on its end. I feel like this blog post title could be “ACOG and SMFM adopt Lamaze International’s Six Healthy Birth Practices.” (Okay, that may be a little overenthusiastic!) I could not be more pleased at the contents of this statement and cannot wait to see some of these new practice guidelines implemented. Judith Lothian, PhD, RN, LCCE, FACCE summarizes the statement and shares highlights of this stunning announcement. – Sharon Muza, Science & Sensibility Community Manager

The alarming and sustained increase in the cesarean rate in the United States has not improved either maternal or neonatal outcomes. In fact, data suggest that there is increased maternal mortality and morbidity associated with cesarean delivery. This statement describes the myriad of complications associated with cesarean and the increased risks associated with cesarean for mother and baby. The authors suggest that potentially modifiable factors, such as patient preferences and practice variation among hospitals, systems, and health care providers are likely to contribute to the escalating cesarean rates. There is a need to prevent overuse of cesarean, particularly the primary cesarean.

source: ACOG

The most common reasons for cesarean include labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. The authors revisited the definition of labor dystocia in light of the fact that labor progresses at a rate that is slower than what we had thought previously. They also reviewed research related to interpretation of fetal heart rate patterns, and access to nonmedical interventions during labor that may reduce cesarean rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in a cephalic presentation can lower the cesarean rate. The authors analyzed the research using a rubric that rated the quality of the available evidence. The result is a set of guidelines that have the potential to substantially decrease the cesarean rate.

These guidelines change the rules of the labor management game.

These are some of the new recommended guidelines:

The Consortium on Safe Labor data rather than the Friedman standards should inform labor management. Slow but progressive labor in the first stage of labor should not be an indication for cesarean. With a few exceptions, prolonged latent phase (greater than 20 hours in a first time mother and greater than 14 hours in multiparous women) should not be an indication for cesarean. As long as mother and baby are doing well, cervical dilation of 6 cm should be the threshold for the active phase of labor. Active phase arrest is defined as women at or beyond 6 cm dilatation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.

Adverse neonatal outcomes have not been associated with the duration of the second stage of labor. The absolute risks of adverse fetal and neonatal outcomes of increasing second stage duration appear to be, at worst, low and incremental. Therefore, at least 2 hours of pushing in a multiparous woman and at least 3 hours of pushing in a first time mother should be allowed. An additional hour of pushing is expected with the use of an epidural, as there is progress. Interestingly, there is no discussion of position change during second stage, including the upright position, to facilitate rotation and descent of the baby. Also, the authors note that second stage starts at full dilatation rather than when the mother has spontaneous bearing down efforts. Research suggests it is beneficial to consider the start of second stage when spontaneous bearing down by the mother begins. (Enkin et al, 2000; Goer & Romano, 2013). Using this definition might also decrease the incidence of cesarean.

Instrument delivery can reduce the need for cesarean. The authors note concern that many obstetric residents do not feel competent to do a forceps delivery.

Recurrent variable decelerations appear to be physiologic response to repetitive compressions of the umbilical cord and are not pathologic. There is an in depth discussion of fetal heart rate patterns and interventions other than cesarean to deal with this clinically. Amnioinfusion for variable fetal heart rate decelerations may safely reduce the rate of cesarean delivery.

Neither chorioamnionitis nor its duration should be an indication for cesarean.

Induction of labor can increase the risk of cesarean. Before 41 0/7 weeks induction should not be done unless there are maternal or fetal indications. Cervical ripening with induction can decrease the risk of cesarean. An induction should only be considered “a failure” after 24 hours of oxytocin administration and ruptured membranes.

Ultrasound done late in pregnancy is associated with an increase in cesareans with no evidence of neonatal benefit. Macrosomia is not an indication for cesarean.

Continuous labor support, including support provided by doulas, is one of the most effective ways to decrease the cesarean rate. The authors note that this resource is probably underutilized.

Before a vaginal breech birth is considered, women need to be informed that there is an increased risk of perinatal or neonatal mortality and morbidity and provide informed consent for the procedure.

Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery (even if the second twin is a noncephalic presentation).

These guidelines offer great promise in lowering the cesarean rate and making labor and birth safer for mothers and babies. They also suggest an emerging respect for and understanding of women’s ability to give birth and a more hands off approach to the management of labor. Women will be allowed to have longer labors. Obstetricians will need to be patient as nature guides the process of birth. Hospitals will have to plan for longer stays in labor and delivery. And women will need to have more confidence in their ability to give birth. Childbirth educators can play a key role here. The prize will be safer birth and healthier mothers and babies.

The authors rightly note that changing local cultures and obstetricians’ attitudes about labor management will be challenging. They also note that tort reform will be necessary if practice is to change. It’s interesting to consider whether standards of practice based on best evidence (as these guidelines are) rather than on fear of malpractice might make tort reform more likely.

The American Academy of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine are to be applauded for their careful research and willingness to make recommendations for labor management based on best evidence. These guidelines provide direction for health care providers and women and will make a difference in not just the cesarean rate but women’s experiences. The game has changed. It is a most welcome change.

What are your first impressions after learning of the elements of this new ACOG/SMFM statement? What impact do you think these changes will have on the care that women receive during labor and birth? Are you considering what barriers to change might exist in the hospitals you serve? How will you share this new information with the families that you work with? As a side note, I found it interesting that this Consensus statement did not suggest using midwives for normal, low risk women. Research has consistently shown that midwives working with low risk populations can reduce the cesarean rate. – SM

I am interested in the 0% rate of shoulder dystocia and 3rd/4th degree lacerations with cesarean delivery. While this is true, I regularly assist at c-sections, and it is not unusual to have significant difficulty in getting the baby out through the incision. This can lead to lacerations of the uterus and/or extensions of the uterine incision which can make future vaginal delivery much more risky. It is also not uncommon to require forceps or vacuum to deliver the baby through the incision. Both of these carry increased risks for infant and possible risk of laceration for the mother. I think this is important to acknowledge.

@Janelle Komorowski
I was thinking the exact same thing Janelle! All of us who see enough C-Sections have seen a surgeon struggle to get the baby out and it is terrifying. The baby often needs to be resuscitated afterwards. Vacuums are becoming more common to avoid this, so a C/S does not save babies from a vacuum. They should have taken that into account too.

@janelle and @sarah, c/s that require vacuum extractions are often the ones done after the mother has been pushing for several hours and baby is in deep transverse arrest. To minimize those perhaps providers should keep to second stage guidelines, and if progress is not being made, the c/s should be called. Hours and hours of pushing followed by a c/s is grueling for the mother and baby.

@Amy V. Haas
Re: what took so long? It has not been until 2004 or so (when ACOG issued a position statement giving the okay for C/S at maternal request)that much of the research on maternal & fetal outcomes, risks/benefits of caesarean was done in this country. These are studies with large sample sizes, which were well-designed, and done with populations that Ob/Gyns in the US can extrapolate data to… I have always thought C/S maternal request was a bad idea, but now there is good data to back that up, as well as data against early induction. Hooray for ACOG & SMFM for being willing to change their stance (in a move that will definitely be unpopular!!) in the face of new evidence.

Now we need to get some of the expectant mothers to be patient and WANT to carry the fetus to 40+ weeks. We get so many “frequent flyers” coming in again and again and our doctor’s finally give in to induce, currently at 39 weeks. Many of these mothers do not have private insurance and these frequent visits cost us all a lot of money. Sad to say, I don’t think educating them will help!

OB-Gyn and hospital staff used to very medicalized ways of giving birth may want to invite midwives and OB-GYn socialized in more “reasonnable” environments… learn from others’ experiences. Difficult to start from scratch if all what you saw was techno-birth… There are interesting experiences in the US and in Europe (UK, NL… for instance) within safety. Most women can give birth without being induced, augmented and cut…

This is the best news I have heard in a long time. I am so pleased with this statement and look forward to helping to make the change in the hospital where I work as a L&D nurse, but even more important, it will make it easier for me to practice according to ACNM guidelines once I graduate as a CNM. Thank you ACOG and SFMF for seeing the evidence and changing the game, this is what mothers and babies truly need.

@Janelle Komorowski: The “3rd and 4th degree lacerations” refers to perineal laceration in the mother, not an injury to the child.

A mother who delivers by planned c-section never suffers perineal injury. Yes, there are other risks unique to cesarian birth, but perineal tears are one complication that only occurs with vaginal birth.

I’m not a doctor or nurse, but do have a child born with a life threatening chronic condition. I am glad to read that they are putting more emphasis on letting the woman’s body determine when the baby will be born, but I do hope that it won’t make mothers and doctors less likely to perform a c-section when the child IS in distress. My first son (the one with the birth defect that was suppose to cause him to be stillborn) was born vaginally. It was a VERY fast labor and I had been told if his heart rate dropped, they would not do a C-section because they didn’t want to risk my life for a baby that was going to die anyway. He came at 35 weeks, but was over 8 pounds (that “baby” will be 22 in April) I’m hoping that this report won’t prompt more doctor to say this to their patients because of the increased risks of a c-section. My second son was huge and breech. I was not given an option other than a c-section. I just assumed it was because of his size and being breech that it wasn’t a possibility to turn him. He did have breathing problems at birth, but he was also just over 4 weeks early. He was almost 10 pounds and I wonder if there would have been any way to deliver him vaginally.

I know it bothers me to see women who just want to have their child on a certain day, or a doctor who doesn’t want to come in on a weekend, so would rather schedule a c-section. Children aren’t meant to be convenient!

Hoping that this will help all mothers and babies to get the care they need without putting them at additional risk.

@shelly dowdle….wow. Do you feel a c section would have benefited your first born? Without knowing what his condition was/is…it’s hard to know how to comment…but 20 years plus later it still seems to be an issue…the second birth….jeez 10 lbs at 4weeks early? Did they “let” you go into labor? Check for diabetes? Do an amnio? I feel your pain….I had four c sections, tried to vbac twice, unsuccessfully. And to this day feel a little PTSD’d by all events. BUT, I have to tell myself today, they are here, healthy and I am grateful….we cannot change the past. I try to remember when I was so desperately trying to avoid what a wise friend told me…that she understood that I wanted a natural childbirth, but that ten years down the road it would only matter that they were here and healthy. Not the manner in which they were born. With your first child, your story may be different. I wish you peace.

Really interesting – I have been advocating a seachange in labour management in the interdisciplinary course I have been running for doctors, midwives and mothers -(called the art of delivery – http://www.artofovd.com)
Times and measurements from my reserach are arbitrary and have little scientific grounding – unless of course there is fetal distress – which from my ressarch there usually isn’t. Understanding decels and what they mean is also taught in the CTG toolkit – with the 6S’s used to quickly determine the risk of hypoxia.
A longer passive second stage, revamping of long forgotten positions that correct malposition and asynclitism and correct the 3P’s ( strengthen contractions, ease fretal distress and open up the pelvis) – and of course thorough training in the art of operative vaginal delivery will see Caesarean rates topple especially at full dilataion which is becoing a commin trend.
Crucial especially in the developing world where a Caesraean has the potential to develop into severe sepsis and marked mortality and morbidity.

Its interesting and uplifting that NURSING MEASURES can make a huge difference and that evidence based practice is making all providers take notice. Often times it is my OB/GYN husband that is arguing with nurses trying to convince them about the benefits of labor support and skin to skin care after birth. These are nursing measures that have been taught for years and its nice to see validation, but too bad that to be believed it had to come from ACOG. A good labor nurse is worth her weight in gold. A good labor nurse makes the difference in decreasing CS, limiting inductions through hard stop policies, and providing skin to skin care to increase breastfeeding and bonding. Whew! Let’s all get on the same page!

Would be a nice change if we are able to take away the fear in childbirthing , I will be happy to see mothers confident in their abilities to give birth and not so many stories of regreats. Keep working for moms, Thank You, Julie le Guerrier Canadian Nurse IBCLC now working in pharmacies near Montréal

I plan on providing my clients with this information. It is terribly exciting!

Kathleen re: “it will not matter how they were born 10 years later”. I cannot change that my cesareans were enormously traumatic. They each altered me permanently and wounded me deeply. But from their births I have loved both children unconditionally. As adults they are leading happy and successful lives. I still feel strongly attached to both. That love and attachment does not obliterate the trauma of those coerced CSs. Perhaps it does for others. Having said that, I assure you that I am nonetheless a happy person.

I agree wholeheartedly with Shauna that a good labor nurse is surely worth her weight in gold. I have had the good fortune to work with a number over the years.

It is unfortunate that the report makes no mention of the fact that midwifery care is known to decrease the rates of many interventions, including Cesarean. most of the points make in the paper have been advocated by midwifery for many years.

Excellent news and great for patients. But …… They also presented a study showing marked increases in neonatal problems and deaths in midwife home births versus midwife hospital birth so everyone pay attention to the pendulum …..remember SAFETY of mom and baby !

At the first view I also would say this is fantastic guidelines…but, now that I’m looking at them with really attention (because I’m translating them to Portuguese), I have to say that I’m disappointed. In fact, this is just what have been saying for many years, with one more concern to me, that they show they have not learning anything about physiology and with midwifery model care. They don’t mention any preventive measures.
I’m really concern that this will not change too much, and could carried out more interventions particular to babies.
For example:
– Fetal heart rate monitoring
They don’t mention intermittent monitoring, they mention invasive techniques to confirm no reassuring FHR…

As a Doula and Activist, of course there are some recommendations that we need to be happy with, but, to be honest, I really don’t expect too much change from this kind of medical model of care, as they don’t act on prevention, like midwifery care.

Anyway, yes it’s important consumers information that this guidelines are a recent consensus, but they also must be informed of pros and cons of each one, and what are there alternatives.

This is overall very good news – clearly the C/S rates needs to be lowered. Increased doula activity, increased midwife involvement, and more patience with the labor process would certainly be beneficial. My only concern with the ACOG document (and many of the posting noted here)is that there really is no good evidence that labor induction per se increases the risk of cesarean delivery. In fact, the opposite really might be true. One simply cannot trust the findings of studies that compare childbirth outcomes that occur after labor induction to outcomes that occur after spontaneous labor – rather the comparison should be between induction NOW and expectant management until delivery LATER (where delivery could follow either spontaneous labor or labor induction [at a later gestational age]). Studies that have correctly modeled the impact of labor induction on childbirth outcomes have generated data suggesting that better outcomes occur with labor induction (Stock – lower stillbirth rates, Darney – lower C/S rates, Nicholson – lower AOI scores and lower NICU rates). Recent data out of Washington State suggests that since the imposition of the strict 39-week rule (that most people seem to applaud) there have been approximately 20 additional term stillbirths per year. That equates to over 1000 per year in the whole USA. Per year. We really really do not know what impact labor induction has on C/S rates (might raise the rate, might lower the rate), but is limiting the use of labor induction worth what might be the cost (as measured in maternal/paternal/societal grief)? And whose decision should it be? Obstetricians with their conservative approach? Midwives with their holistic approach? Or patients themselves who have their own set of values and beliefs and preferences. Seems to me – because we really really do not have study findings that can clearly direct us – we should provide patients with the best information we can muster and then support them in their choice.

First – a few observations, as I do not believe these new guidelines are anything to celebrate and may even harm the health of women and babies. First, it is important to note that the table of risks and benefits presented here does not distinguish between emergent cesareans and planned cesareans – or even urgent cesareans. These are very important distinctions. When an emergent cesarean is performed it is because the health and safety of either woman or child is in grave danger. These are procedures where the woman is often put under a general anesthetic and the child may need a fair amount of assistance after the birth. Most often, these surgeries are undertaken on a woman who is at her physical limit – having undergone the rigours of labour. The outcomes of these surgeries are understandably not as good as a spontaneous vaginal delivery BUT compared to the outcome that would occur if intervention were not to happen, the outcomes are far superior. Next is the urgent cesarean – these are cesareans that are performed when the risk of needing an emergent cesarean are beginning to mount – but neither mother nor baby is in distress. These tend to be more risky than planned cesareans, but less risky than emergent cesareans – and these are the cesareans that this new guideline likely targets. Lastly, there are the planned cesareans – including maternal choice cesareans, repeat cesareans, cesareans for breech, etc. These are the least risky cesareans that are typically carried out after 39 weeks but before the commencement of labour.

Note – all emergent cesareans and most urgent cesareans are the result of planned vaginal births that are no longer feasible.

Promoting these new guidelines might just push more women to undergoing truly emergent cesareans, many of which might be very traumatic and some of which will have horrific outcomes. The guidelines might avoid some cesareans, but at an unacceptable cost. Note – increasing the rate of instrumental deliveries might also increase the rate of 3rd and 4th degree tears and long run sequalae, and should not be seen as a generally positive thing.

What needs to happen – is that women need to be given informed consent, a discussion about their particular circumstances and the risks and benefits of the options available to them (proceeding with the TOL, instrumental delivery and cesarean), and for those women to be supported in whatever choice they make for themselves and their baby.

Focussing on the cesarean rate is perhaps the greatest threat to the health and wellbeing of women and their babies. We need to focus on mothers and what they need to make the best decisions for themselves and their babies – regardless of what that might mean for the rate of cesareans.

@Jim Nicholson
I really appreciate your comments here. I’ve been studying the Safe Prevention of the Primary Cesarean Delivery article, as well any additional research I can find about the risk and benefits of inductions. I want to be sure I’m presenting the facts of inductions to my clients in an evidence-based, unbiased manner. Any chance you could help me properly interpret this statement, “Studies that compare induction of labor to its actual alternative, expectant management awaiting spontaneous labor, have found either no difference or a decreased risk of cesarean delivery among women who are induced.” This would make more sense to me if it had some timeline attached to it….For example, a study of women who had an elective induction at 40 weeks vs. women who continued with expectant management and either began labor spontaneously or were induced by 42 weeks. What exactly does this statement mean in context?